Free Form CA - Federal

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3 Form CA
REGISTRATION NUMBER

For Supplementary Registration
UNITED STATES COPYRIGHT OFFICE

TX

TXU

PA

PAU

VA

VAU

SR

SRU

RE

EFFECTIVE DATE OF SUPPLEMENTARY REGISTRATION

Month

Day

Year

DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET.

A B

Title of Work Registration Number of the Basic Registration Name(s) of Author(s) Year of Basic Registration Name(s) of Copyright Claimant(s)

Location and Nature of Incorrect Information in Basic Registration Line Number _________________________ Line Heading or Description _____________________________________________________________ Incorrect Information as It Appears in Basic Registration

Corrected Information

Explanation of Correction

C

Location and Nature of Information in Basic Registration to be Amplified Line Number _________________________ Line Heading or Description _____________________________________________________________ Amplified Information and Explanation of Information

MORE ON BACK



· Complete all applicable spaces (D-G) on the reverse side of this page. · See detailed instructions. · Sign the form at Space F.

DO NOT WRITE HERE Page 1 of pages

FORM CA RECEIVED

FORM CA

FUNDS RECEIVED DATE

EXAMINED BY CORRESPONDENCE REFERENCE TO THIS REGISTRATION ADDED TO BASIC REGISTRATION YES NO DO NOT WRITE ABOVE THIS LINE. IF YOU NEED MORE SPACE, USE A SEPARATE CONTINUATION SHEET. Continuation of: Part B or Part C

FOR COPYRIGHT OFFICE USE ONLY

D

Correspondence: Give name and address to which correspondence about this application should be sent.

E F G

Phone (______)______________________________ Fax (______)______________________________ Email ______________________________________ Deposit Account: If the registration fee is to be charged to a Deposit Account established in the Copyright Office, give name and number of Account. Name _____________________________________________________________________________________________________________________________ Account Number ________________________________________________ Certification* I, the undersigned, hereby certify that I am the: (Check only one) owner of exclusive right(s) duly authorized agent of ____________________________________________________________________ Name of author or other copyright claimant, or owner of exclusive right(s) of the work identified in this application and that the statements made by me in this application are correct to the best of my knowledge. Typed or printed name __________________________________________________________________________________________________ Handwritten signature (X) Date _______________________________ author other copyright claimant

Certificate will be mailed in window envelope to this address:

Name



YOU MUST:
· Complete all necessary spaces · Sign your application in Space F

SEND ALL ELEMENTS IN THE SAME PACKAGE:
1. Application form 2. Nonrefundable filing fee in check or money order payable to Register of Copyrights

Number/Street/Apt

City/State/ZIP



MAIL TO:
Library of Congress Copyright Office 101 Independence Avenue SE Washington, DC 20559-6000

*17 USC §506(e): Any person who knowingly makes a false representation of a material fact in the application for copyright registration provided for by section 409, or in any written statement filed in connection with the application, shall be fined not more than $2,500. Form CA­Full Rev: 07 / 2006 Print: 07 / 2006-- ··,000 Printed on recycled paper U.S. Government Printing Office: 2006-···-··· / ··,···